This book tells it like it is without a great deal of concern for political correctness or the tentative guarded language that so often hides the truth about addiction, recovery, and relapse.

After 40 years of following the new research and treatment practices for addiction, Terry Gorski became frustrated at the misinformation about alcohol and other drug addictions and the narrow and incomplete approaches to treatment, recovery and relapse prevention.

In this book, Terry provides the best information on the current science-based upon an accurate understanding of what the core addiction syndrome is and what the an effective addiction treatment process needs to look like if it is to increase the chances of recovery and decrease the risk of relapse.

This book is easy to read and loaded with useful information. The book can be quickly read from beginning to end, and then kept as a handy reference to find specific information that can be used as a guide to manage the problems and crises that are so often a part of the addiction and recovery process.

The message is simple: addiction is a biopsychosocial disease. science-based understanding of what the core addiction syndrome is and what the core addiction treatment process needs to look like if it is to increase the chances of recovery and decrease the risk. Here are some of the key ideas developed in depth with the book:

Addiction is a biopsychosocial disease. Bio means biological or of the body, Psycho means psychological or of the mind, Social means the relationships that develop among people and with the social and legal systems that are needed for responsible living.

Biologically, addiction is marked by brain dysfunction that disrupts the reward chemistry of the brain creating cycles of intense euphoria and powerful craving.

Psychologically addicted people slowly adjust their ways of thinking, feeling, acting that allows them to deny and rationalize the problems caused by the it addiction.

Gradually, over time, an addictive beliefs develops that create a powerful denial system. This denial blocks the ability to recognize the addiction, interferes with the ability to ask for and accept help, and creates a deadly spiral of progressively more severe relapse episodes.

Socially, addiction pushes away sober and responsible people while attracting and feeling attracted to addicted and irresponsible people. The result is a tragedy. The addict abuses, disregards, and destroys those who love and try to help them. Active addicts set themselves up to be exploited by other addicted people and are vulnerable to predators who use and abuse them.

Most importantly Straight Talk About Addiction provides hope. Addiction and be understood, recovery is possible, and relapse can be prevented it effectively managed should it occur.

This book is easy to read and understand. It is loaded with useful information. Many people read it from beginning to end to get a comprehensive understanding of addiction, recovery, relapse, and related problems. Many people keep the book handy so they can use it as an easy-access reference to find useful information that can be used to effectively manage addiction-related problems.

The message is clear: Recovery is possible. Relapse can be prevented or effectively managed should it occur. There is hope.

Stress management is a critical key to staying away from alcohol and other drugs[i][ii]during the critical first two weeks of recovery.[iii] It is important for people in recovery to learn how to recognize their stress levels and use immediate relaxation techniques to lower their stress. [iv][v]

Recovering people are especially vulnerable to stress.[vi] There is a growing body of evidence that many addicted people have brain chemistry imbalances that make it difficult for them to manage stress in early recovery. The regular and heavy use of alcohol and other drugs can cause toxic effects on the brain that create symptoms that cause additional stress and interfere with effective stress management.

Many people who are in recovery from addiction have serious problems with Post Acute Withdrawal (PAW). PAW is a bio-psychosocial syndrome that results from the combination of brain dysfunction caused by addictive alcohol or drug use, and the stress of coping with life without drugs or alcohol. PAW is caused by brain chemistry imbalances that are related to addiction. PAW disrupts the ability to think clearly, manage feelings and emotions, manage stress, and self-regulate behavior.

PAW is stress sensitive. Getting into recovery causes a great deal of stress. Many recovering people never learn to manage stress without using alcohol or other drugs. Stress makes the brain dysfunction in early recovery get worse. As the level of stress goes up, the severity of PAW symptoms increase. As PAW symptoms get worse, recovering people start losing their ability to effectively manage their stress. As a result, they are locked into constant states of high stress that cause them to go between emotional numbness and emotional overreaction. Since high stress is linked to getting relief by self-medicating stress with alcohol or other drugs, high stress gets linked with the craving for alcohol or other drugs. So one of the first steps in managing craving is to learn how to relax and lower stress without using alcohol or other drugs.

The severity of PAW depends upon two things: the severity of brain dysfunction caused by addiction and the amount of stress experienced in recovery. The first two weeks of recovery is the period of highest stress in recovery. This high stress occurs before you have a chance to learn how to manage it in a sober and responsible way. Since you cannot remove yourself from all stressful situations, you need to prepare yourself to handle them when they occur. It is not the situation that causes stress; it is your reaction to the situation.

According to the National Institute on Drug Abuse, exposure to stress is one of the most powerful triggers for relapse to substance abuse in addicted persons, even after long periods of abstinence. Stress can cause a problem drinker to drink more, a person using prescription medication to use more than prescribed, and an illicit drug user to get more deeply involved in the drug culture than they could ever imagine. The high stress of the first two weeks of recovery can activate powerful cravings that make people want to start self-medicating with alcohol or other drugs in spite of their commitment to stop and stay stopped.

There is a simple tool called The Stress Thermometer that can help you to learn how monitor your stress. There is a simple immediate relaxation technique called Relaxed Breathing that can help you noticeably lower you stress in two to three minutes. First, let’s talk about the Stress Thermometer.

The Stress Thermometer

The Stress Thermometer is a self-monitoring tool that teaches people to become aware of their current stress levels, notice increases and decreases in stress at different times, and encourages the use of immediate relaxation techniques to lower stress as soon stress levels begin to rise. The Stress Thermometer makes it possible to manage stress before craving for alcohol or other drugs is activated. Lowering stress can also lower cravings. Lowering cravings can help you to turn off denial and addictive thinking. (More about this later).

The concept of using a stress thermometer came from thinking about how we use a temperature thermometer to measure our body temperature. When we take our body temperature we use a thermometer to tell us accurately and objectively what our body temperature is. When we use a stress thermometer, we use a system for self-monitoring our stress levels that can tell us accurately and objectively how high our stress levels are.

What the Stress Levels Mean

Low Stress/Relaxation: Stress levels 1, 2, and 3. These stress levels are coded blue because they are cool and relaxing.

Stress Level 1: Deeply Relaxed/Nearly Asleep: At Stress Level 1 you are in a state of deep relaxation and nearly asleep. Your mind is not focused on anything in particular and you feel like you are waking up in the morning to a day off and can just let your mind drift in the deeply relaxed state.

Stress Level 2: Deeply Relaxed/Not Focused: As you come back from a state of deep relaxation you enter Level 2, during which you stay very relaxed, but begin to notice where you’re at, what is going on around you. You can stay in that state and just be aware and deeply relaxed. Eventually we will either go back down to Level 1 and then perhaps falls asleep or else you will move up to Stress Level 3.

Stress Level 3: Deeply Relaxed/Focused:At stress level 3 you get focused and start to think about getting yourself back into gear and getting going. In other words, you are getting ready to “kick-start your brain” so you can move into a functional stress level to begin getting things done.

By practicing the Relaxed Breathing Technique (this will be explained on page 19) most people can learn to put themselves in a relaxed state (Stress Level 1, 2, or 3), stay there for a few minutes, and then come back feeling refreshed and relaxed. It is important to remember that this will take time and practice. In our culture people are taught to work hard and burn themselves out. People don’t get much training on how to relax. People who get a euphoric effect from using alcohol or other drugs don’t need to. When they get the “right amount” in their system they shut down their stress chemistry, turn on the pleasure chemistry, and feel relaxed.

It is important to practice relaxation four times per day. I recommend linking it to meals: Take five minutes in the morning before breakfast, five minutes at lunch, five minutes at dinner, and five minutes to relax before going to sleep. Taking these stress breaks will make it easier for you to stay at a functional stress level and bounce back quickly from high stress situations.

With that in mind, let’s look at the “Functional Stress levels.”

Functional Stress:Stress levels 4, 5 & 6 designate the zone of functional stress. They are coded green because green is a color that represents “go”. At stress levels 4, 5, and 6 we are experiencing stress levels that are high enough to give us the energy to get started, keep going, and get things done. The stress, however, is not so high that in interferes with what we are doing.

Stress Level 4: With effort we get Focused and Active.

Stress Level 5: We operate at high performance, a state of free flow with little or no effort.

Stress level 6: We can keep on going but it takes effort and we notice we are getting tired. It’s called free flow with effort. This is a good time to take a short break if you can to get your stress level back down to a level five.

Acute Stress Reaction:Stress levels 7, 8, and 9 are coded yellow. The color yellow represents caution. At stress levels 7, 8, and 9 we are experiencing an acute stress reaction. The word “acute” means immediate and severe. The good thing about acute stress is that if we notice it early and know how to relax, by taking a short break and using a relaxed breathing technique for example, we can lower our stress and get back into the functional zone. When we enter stress level 7 it means that our immediate levels of stress have gotten so high that we can’t consistently function normally. We’re in danger.

Stress level 7: Space Out: at a stress level 7 we space out. Our mind goes somewhere else and we don’t even know we were gone until our mind comes back on task.

Stress level 8: Driven and Defensive: at stress level eight we are driven and defensive. Our stress chemical has been activated and we are running on an adrenaline rush that is keeping us compulsively on task. The problem is that if someone or something interrupts us we become defensive and can easily move into stress level 9.

Stress level 9: Overreaction/Survival Behavior: at stress level 9 our automatic survival behavior takes over. The three basic survival behaviors that everyone has are: fight (irritated, angry, agitated); flight (anxious, fearful, panicked); and freeze (we feel an agitated sense of depression and indecision. We freeze up and can’t make a decision or move.) On top of these three core survival behaviors we learn more sophisticated survival behaviors from our family of origin, life experiences, education or special training in stress management, emergency management, martial arts, or combat. For that training to automatically come into play, we must have practiced it over-and-over again until it became habitual. In sports, emergency services, police work, and military operations these are called trained response. When our stress hits level ten our brain won’t allow us to rise to the situation. The emergency brain response will always lower us to the level of our training. In an emergency, all we can rely on are our automatic responses that we learned to perform on cue without having to think about it.

Traumatic Stress Reaction: Stress levels 10, 15, and 20 are coded red. Red is for stop. At this point our stress levels are so high that our brains and minds are at risk of shutting down. There are three levels of stress that can occur in the red zone of traumatic stress.

Stress level 10: Loss of Control: We automatically start using our survival behavior and we can’t control it. We are on automatic pilot and we will go through our learned survival responses one-by-one. This means we will cycle through stages of extreme anger (fight), extreme fear (flight, and extreme inner conflict or ambivalence (freeze). It is important to remember that all people with serious alcohol and drug problems have conditioned themselves with a survival behavior called “seek and use drugs to handle this.” So it is not unusual for a person at a stress level ten to get into drug seeking behavior and start using alcohol or other drugs.

Stress level 15: Traumatic Stress: At level 15 our high stress overloads the brain and we mentally disconnect from what is happening to us. Our stress is so high that we can’t stay consciously connected with out bodies. We may go into a state of daze, shock, and dissociation. Our mind can start to play tricks on us and things around us may seem bigger, or closer or farther away than they really are. We may start feeling confused and disoriented. It may seem like we are moving in slow motion. Some people feel like they have floated out of their bodies and it seems like they are watching themselves go through the experience.

Stress level 20: Collapse/Psychosis: When our stress levels hit a level 20 our brains can’t take the high level of stress and fatigue. We may collapse, enter an exhausted state of stupor or restless sleep, move into a vivid fantasy world or a world of memories or dreams, or become unconscious.

Any time people experience a “level 10 plus” state of stress; it will take a while after the stress stops for our brain to start functioning normally. When this is a short-term period of adjustment it is called an “acute trauma reaction.” When in it is a longer-term reaction it is called post traumatic stress disorder.

If you have ever experienced a “level 10 plus” stress experience – which can happen when you are the victim of crime, accidents, caught in a burning house, participating in combat, having been assaulted, etc. – it is important to discuss these experiences with your doctor or therapist. This is especially important if the high stress experience you had causes problems that you did not have before it occurred.

Space Out: My brain can’t handle the stress, turns off for a second, and I gone blank and don’t even realize it until my brain turns back on a few seconds later.

——————————– The Brain Shift Gears ——————————–

Level 6:

Free Flow Activity With Effort I’m getting tired and have to push myself to keep going.

Level 5:

Free Flow Activity With No Effort: I’m totally into what I’m doing and get lost in the process. I’m on automatic pilot.

Level 4:

Become Focused and Active With Effort: I make a decision to dig in and get to work. It takes an effort to get started.

——————————– The Brain Shift Gears ——————————–

Level 3:

Relaxed – Aware But Not Focused: I’m relaxed and aware of what’s going on around me. I’m beginning to realize that I need to get going.

Level 2:

Very Relaxed – Not Aware & Not Focused: I’m so relaxed that I’m not aware of what’s going on around me. I’m disconnected and don’t want to notice anything.

Level 1:

Deeply Relaxed – Nearly Asleep: I’m so deeply relaxed that I’m drifting in and out of a dreamy type of sleep state filled with active fantasy or daydreaming.

The Most Important Stress Management Tool is
The Conscious Awareness of the Rise and Fall of Your Stress Levels.
This is Achieved Through Self-monitoring.

Measuring Levels of Stress

Notice that you are measuring your personal perception of stress, which is a combination of three things: (1) the intensity of the stressor (the situation activating stress); (2) your ability to cope with or handle the stressor; and (3) your level of awareness while you are experiencing the stress.

It is possible for you to score yourself very low on the stress thermometer even when your stress is very high. This can happen because: (1) you are distracted and involved in something else (like managing the crisis causing your stress); (2) your stress is so high that you are emotionally numb and don’t know what you are feeling; (3) if you have lived with such high stress for such a long time that you consider it normal; and (4) you have trained yourself to ignore your stress.

The first step in learning how to manage your stress is to learn how to recognize and evaluate your level of stress and by learning how to quickly get back into a low stress level by using a Relaxed Breathing Technique. Let’s start by looking at how you can improve your stress awareness.

Improving Stress Awareness

The best way to learn to be aware of your stress level is to get in the habit of consciously monitoring your stress level. You can do this by using a mental tool called The Stress Thermometer, (page 17). The first step is to imagine that you have an internal stress thermometer that starts in the pit of your stomach and ends in your throat. The lowest reading on the stress thermometer is zero and represents a deep sense of relaxation that is so complete that you want to fall asleep. At a stress level seven or eight, your stress becomes so intense that you start shutting down, getting defensive, or avoiding the issue that is causing the stress. If you can’t manage or get away from the stressful situation, at a level ten you lose control and start believing that you can’t handle the situation and that you or someone you love may be hurt or killed. These extreme feelings of stress are called trauma.

When most people hit a stress level of seven or higher they are not able to respond to constructive criticism or to make sense out of their emotional experiences. At stress levels between seven and nine most people start acting compulsively, overreact to things going on around them, and start using automatic habitual survival behaviors that may or may not solve the problem and lower stress.

This is why it is so important for you to learn to recognize your stress levels when they start hitting a level seven and learn how to quickly lower them. You can do this by using an immediate relaxation response technique called Relaxed Breathing any time you notice your stress hitting a level seven or above. So you have four goals in this exercise:

(1) To learn how to get into the habit of noticing when your stress is getting up to a level seven or eight;

(2) To learn how to quickly lower your stress by using the Relaxed Breathing Technique;

(3) To figure out what is happening and how you are thinking and feeling about what is happening that is causing your stress to go up; and

(4) Manage the stressful situation by responsibly getting out of the situation or learning how to manage your thoughts, feelings, and behaviors that will allow you to stay cool and relaxed even tough you are in a tough situation.

Monitoring Your Stress – Body Awareness

Body awareness is a technique that allows you to recognize how your body physically reacts to stress. It can be a powerful skill to use in stress management because as you notice the stress in different parts of your body, you will start to relax the part of the body you are noticing. With enough practice your body will automatically start identifying and releasing stress before you become consciously aware of it. Muscle tension is the primary way your body let’s you know that you are experiencing stress. Consciously using a systematic body awareness technique whenever you think about it and at least four times per day will start you on the road to teaching your body to automatically recognize and release stress. Here’s how the technique works:

Begin by closing your eyes. You will concentrate on one muscle group at a time, tensing and releasing and being aware of how tight the muscle is as you focus on it. If the muscle feels tight as you begin, this may indicate you store stress in this muscle. Begin with focusing on your toes and slowly move up your body. Tighten your toes and release, flex your calves and release, tighten your thighs and release, tighten your stomach muscles and release, fist your hands and release, tense your shoulders and release, clench you jaw and release, squint your eyes and scrunch your face and release. Any time you encounter tension in a muscle, record that muscle tension and be aware that you are holding stress there. This will help you in developing a personal stress reduction plan and using exercises and techniques to release pent-up tension.

Reducing Your Stress – Relaxed Breathing

There are a number of different relaxation methods. For the purpose of this workbook I am going to teach the easiest and most effective. It is called Relaxed Breathing. It is so effective that military, police and firefighters are taught to use it to lower their stress when responding to emergencies. Here’s how it works:

Relaxed Breathing, often called combat breathing in the military or tactical breath by police and emergency responders, is designed for both before and during stressful times to calm you down and help you relax. In terms of the stress thermometer, relaxed breathing is used before a stressful situation to calm you down and get you ready to be at your best. It is used during a stressful situation to keep your stress from going above that critical Level 7, where your brain turns off and automatic defensive behavior and cravings kick in.

Early in recovery, thinking about and talking about your use of alcohol or other drugs will cause some of your highest stress. The catch 22 is this – if you don’t talk about it, the thoughts will keep coming back like a ghost in the night that haunts moments that should be quiet and restful. Each time you expel the ghost by refusing to think and talk about the “real problems” the ghost goes away for a little while and comes back stronger. Your denial and resistance is strengthened, the intensity of your craving goes up, and your ability to think rationality about what you need to do goes down. As a result the voice of this “stress ghost” grows into a full-blown “stress monster” that can literally take your brain hostage and make you believe that self-medication with alcohol or other drugs is the best or only way to get back in control of yourself and your life.

Step 1: The first thing you need to do is to convince yourself that you can manage and reduce stress without having to self-medicate. There is another way. That way involves learning how to control your breathing.

Step 2: Practice relaxed breathing in a safe environment when you are not stressed. Just go through the steps and get used to them.

Step 3: Get used to rating your stress level. Initially you may need to use the stress thermometer, but with a few times of practice (four times per day for three or more days) the use of the scale will be an automatic tool that you will use whenever you check out you stress level.

Step 4: Take control of the process by stressing yourself out and then relaxing yourself using the relaxed breathing technique.

Sit in a quiet place where you will not be disturbed for ten or fifteen minutes. Take a deep breath and do a quick body checks. Then on a sheet of paper write the word START and underneath or next to it rate your stress level.

For example, I would do a body check and write: START = 6. I am still relaxed and able to think and respond, but I am tired and on the edge of spacing out.

Step 5: Stress yourself out! Your heard what I said. Think about the things you usually think about that raise your stress. Be sure to beat yourself up about your drinking and drugging, how stupid you were, the problems it has caused and how you will never-ever be able to repair the damage you have done to your life. Stop the process before your stress hits a level 9 or 10 and you go running out of the room. Then write the words: AFTER STRESS and rate your stress level. Most people find it easy to raise their stress.

For example, after beating myself up for about 60 seconds I would write: AFTER STRESS = 8. I feel myself driving myself and notice the thoughts start to take on a life of their own. If someone interrupts me at this moment I could easily over-react.

Step 6: Relax yourself! You heard me. Do what you need to do to relax. This is the problem for many people, especially people who use alcohol, prescribed medication, or other drugs regularly and heavily. They can stress themselves out easily enough, but other than self-medication they have no way to calm themselves down. So try this:

Take a deep breath and hold it for a moment until your lungs feel just a little uncomfortable, hold your breath for a moment, and then exhale all the way out. Hold your breath for a moment with your lungs empty and then slowly inhale again. Start to breath a slow rhythmic count of four: “INHALE– two- three – four; HOLD – two – three – four; EXHALE – two – three – four; HOLD – two – three – four. Then start the cycle over by inhaling to the count of four. Repeat the cycle five times. Imagine the stress gathering in your lungs as you inhale and hold. Imagine the stress releasing from your mouth as you exhale and hold. That’s it.

Now rate your stress again. Look at the stress thermometer and see what happened. Then write the words: AFTER followed by your stress rating.

For example I would write: AFTER RELAXING = 4 (remember I’ve been practicing a long time). So the record of my session looks like this:

START =6; AFTER STRESS = 8; BREATHING REPS = 5; AFTER =4.

Don’t force yourself to relax, just do the relaxed breathing, and focus on counting and imaging the stress leaving your body ever time you exhale.

Practice four times per day, at breakfast, lunch, dinner, and before bed. Keep track of your progress. Use relaxed breathing if you notice your stress going up during any of the following exercises.

Footnotes

[i]Stress and increased Relapse Risk: Stress is an important factor known to increase alcohol and drug relapse risk. This paper examines the stress-related processes that influence addiction relapse. First, individual patient vignettes of stress- and cue-related situations that increase drug seeking and relapse susceptibility are presented. Next, empirical findings from human laboratory and brain-imaging studies that are consistent with clinical observations and support the specific role of stress processes in the drug-craving state are reviewed. Recent findings on differences in stress responsivity in addicted versus matched community social drinkers are reviewed to demonstrate alterations in stress pathways that could explain the significant contribution of stress-related mechanisms on craving and relapse susceptibility. Finally, significant implications of these findings for clinical practice are discussed, with a specific focus on the development of novel interventions that target stress processes and drug craving to improve addiction relapse outcomes.

Stress Identification and Management: Stress as verified by clinical observations, patient self-reports, and subjective and behavioral measures have been correlated depressive symptoms, stress, and drug craving during withdrawal. All of theses factors predict future relapse risk. Among neural measures, brain atrophy in the medial frontal regions and hyperreactivity of the anterior cingulate during withdrawal were identified as important in drug withdrawal and relapse risk. This study suggests that stress management would be helpful in preventing relapse especially during the period of withdrawal

[ii]Stress Identification and Management: Stress as verified by clinical observations, patient self-reports, and subjective and behavioral measures have been correlated depressive symptoms, stress, and drug craving during withdrawal. All of these factors predict future relapse risk. Among neural measures, brain atrophy in the medial frontal regions and hyperreactivity of the anterior cingulate during withdrawal were identified as important in drug withdrawal and relapse risk. This study suggests that stress management would be helpful in preventing relapse especially during the period of withdrawal.

[iii]The Role of Stress In Addiction: Both animal and human studies demonstrate that stress plays a major role in the process of alcohol and drug addiction and that a variety of stressors can increase both self-reported stress and measures of biological stress. Among neural measures, brain atrophy in the medial frontal regions and hyperreactivity of the anterior cingulate during withdrawal were identified as important in drug withdrawal and relapse risk. This study suggests that stress management would be helpful in preventing relapse especially during the period of withdrawal.

[iv]Stress and Addiction: Stress plays a major role in the process of drug addiction and various stressors are known to increase measures of craving in drug dependent human laboratory subjects. Animal models of stress-induced reinstatement of drug-seeking have also been developed in order to determine the neuropharmacological and neurobiological features of stress-induced relapse.

[v]Stress-Induced Craving and Cognitive Behavioral Therapy: The Division of Clinical Neuroscience, Medical University of South Carolina, Charleston, South Carolina 29425, USA. (backs@musc.edu) has found that stress-induced craving and stress reactivity may influence risk for substance use or relapse to use. Interventions designed to manage stress-induced craving and stress reactivity may serve as excellent adjuncts to more comprehensive treatment programs. The purpose of this study was to (1) tailor an existing, manualized, cognitive-behavioral stress management (CBSM) intervention for use in individuals with substance use disorders and (2) preliminarily evaluate the effects of the intervention using an experimental stress-induction paradigm. Twenty individuals were interviewed and then completed a psychological stress task, the Mental Arithmetic Task (MAT). After this, participants were assigned to either the CBSM intervention group or a non-treatment comparison group. Approximately 3 weeks later, participants completed a second MAT. In contrast to the comparison group, the CBSM group demonstrated significantly less stress-induced craving (p<.04) and stress (p<.02), and reported greater ability to resist urges to use (p<.02) after the second MAT. These findings are among the first to report on the use of an intervention to attenuate craving and stress reactivity among individuals with substance use disorders. Although preliminary, the findings suggest that systematic investigation of interventions specifically targeting stress management in individuals with substance use disorders should be undertaken.

[vi]Research Society On Alcoholism: This report of the proceedings of a symposium presented at the 2004 Research Society on Alcoholism Meeting provides evidence linking stress during sobriety to craving that increases the risk for relapse. The initial presentation by Rajita Sinha summarized clinical evidence for the hypothesis that there is an increased sensitivity to stress-induced craving in alcoholics. During early abstinence, alcoholics who were confronted with stressful circumstances showed increased susceptibility for relapse. George Breese presented data demonstrating that stress could substitute for repeated withdrawals from chronic ethanol to induce anxiety-like behavior. This persistent adaptive change induced by multiple withdrawals allowed stress to induce an anxiety-like response that was absent in animals that were not previously exposed to chronic ethanol. Subsequently, Amanda Roberts reviewed evidence that increased drinking induced by stress was dependent on corticotrophin-releasing factor (CRF). In addition, rats that were stressed during protracted abstinence exhibited anxiety-like behavior that was also dependent on CRF. Christopher Dayas indicated that stress increases the reinstatement of an alcohol-related cue. Moreover, this effect was enhanced by previous alcohol dependence. These interactive effects between stress and alcohol-related environmental stimuli depended on concurrent activation of endogenous opioid and CRF systems. A.D. Lê covered information that indicated that stress facilitated reinstatement to alcohol responding and summarized the influence of multiple deprivations on this interaction. David Overstreet provided evidence that restraint stress during repeated alcohol deprivations increases voluntary drinking in alcohol-preferring (P) rats that result in withdrawal-induced anxiety that is not observed in the absence of stress. Testing of drugs on the stress-induced voluntary drinking implicated serotonin and CRF involvement in the sensitized response. Collectively, the presentations provided convincing support for an involvement of stress in the cause of relapse and continuing alcohol abuse and suggested novel pharmacological approaches for treating relapse induced by stress.

Stress Management Is Used In The Gorski Relapse Prevention Certification School (RPCS)

Relaxation Training and Mindfulness Meditation are a big part of Relapse Prevention Therapy (RPT). When patients are under high levels of stress, their ability to understand, integrate, and use new skills is diminished. Gorski RPT teaches therapists how to use a form of immediate relaxation training to keep clien’s stress low during the session. It also teaches them to use relaxation methods in the moment so they are more likely to use them in real-life events. For an overview of how relaxation training and a simple tool called the stress thermometer can be used with RPT check out Terry Gorski’s Blog:

I believe the recovery chart depicted her is modified from the framework of the Matrix Recovery Model.

The model is developmental in nature (i.e. their are a series of developmental steps and stages of recovery). The idea of Post Acute Withdrawal is built into the model by intruding the the concept of “hitting the wall” which is a severe episode of PAW. PAW however, was not specifically mentioned in early versions of the model.

The Matrix Model was popular during the years of “The Cocaine Epidemic” in the 1980”s and 1990’s. It was an empirical model growing out of treatment experience and I clinical practice.

As with many other models it was expanded to include all addictive substances without any real evidence it was valid. It implies progressive recovery, with relapse as a treatment recovery failure.

There is no specific relapse prevention plan or emergency plan to stop relapse quickly should it occur. As a result the model, toy knowledge, has not adapted to integrate the chronic life-style related disease model and the need for relapse prevention and management of the course of the entire lifespan.

The model has been used in many programs and helped many people to recover.

I cannot locate the specific diagram and it is not referenced. The idea that neurological symptoms of recovery (PAW) can be predicted by days abstinent is controversial. Stage of addiction, type and amount of drug(s) used, age and health status of the patient, type of treatment, nutrition and stress management effect the progression of recovery.

Developed By Terence T. Gorski for use in Relapse Prevention Therapy (RPT) in 1995

Most relapse prone people have serious problems with stress that can lead to relapse. It is important to teach relaxation techniques that can be used to turn off or significantly reduce the immediate stress response when it occurs. Mindfulness mediation has become a popular evidence-based relaxation method, but there are other relaxation techniques that are also effective.

The Smorgasbord Approach To Relaxation Training

Relaxation training has been consistently integrated into the CENAPS® Model of Relapse Prevention since about 1985. Another blog with cover the seven core approaches to relaxation training and meditation used Certified Relapse Prevention Specialist (CRPS) and found to be helpful in their work.

The Magic Triangle Relaxation Technique is one specific application that integrates one application that has been used in the Relapse Prevention Certification School for many decades. It is not the only method that works, it is one of the methods.

Patients seem to do better when given a choice of relaxation techniques, and opportunity to experiment with the different core techniques, and the ability to choose what work best for them. Many Relapse Prevention Specialists have found that they can easily develop a personal relaxation exercise by combining the core approaches in a personalize script.

The Magic Triangle Relaxation Technique is one of the best techniques for teaching immediate relaxation response training because it involves a combination of deep breathing, guided imagery, and autosuggestion. The technique is called the Magic Triangle Relaxation Technique because it uses the focal image of a triangle to induce relaxation.

Self-Monitoring of Effectiveness

Self-monitoring is an evidence-based practice that is based upon the principle that regular self-evaluation of the effectiveness of a therapy technique tends to increase it’s effectiveness. Cognitive behavior therapists have found that using a simple subjective ten-point scale increases the effectiveness of self-monitoring.

The Stress Thermometer is simple stress scale for measuring the intensity of stress from patients on a self-report basis. The scale ranges from 1 -10 and allows easy measurement of four levels of stress:

Incapacitating Stress (Level 10),

High stress (Level 7-9),

Moderate stress (3-5) and

Low stress (1-3)

Before beginning and the end of each relaxation session ask the patient self-evaluate their current level of stress. At the end of the session, the therapist and patient compare the two scores and discuss which part of the relaxation training was most helpful. By keeping track of the scores and the technique used across sessions, patients can more accurately evaluate what works best for them as individuals. If patients do not perceive their stress level is decreased by the relaxation technique they are using, or if the technique actually raised their perceived stress, they rapidly lose the motivation build relaxation training into their recovery and healthy lifestyle plan.

The Magic Triangle Technique

Here is a detailed description of how to use the technique.

Give a General Relaxation suggestion

“Take a deep breath and sit back in your chair. I am going to teach you an immediate relaxation response exercise called the Magic Triangle Relaxation Technique. Once you learn it, you will be able to use this technique to help you to turn off or significantly reduce stress whenever you become tense or agitated.”

Give the Suggestion of Total Control and Safety

“You will be in total control of this relaxation process. If at any time you feel uncomfortable or frightened, all you need to do is to open your eyes, sit up, and look around the room and you will come back to the present.”

Change Your Body Posture

“Change your body posture in the chair. Sit up straight, put your feet flat on the floor and look straight ahead. Find a spot on the wall or a spot in space in front of you. You can allow your eyes to close if it is comfortable, but you can also leave your eyes open and stare blankly in front of you as you let your mind relax and wander. You can do what feels best for you to do.”

Body-awareness and Relaxation

“Notice your feet. Notice the pressure of your feet on the floor. Notice the feeling in your feet. Now say to yourself: ‘My feet are warm and comfortable. I feel a tingling sense of relaxation in my feet.’” (Repeat this suggestion three to five times)

“Now notice your legs. Notice the feelings in your lower and upper legs. Now say to yourself: ‘My legs are warm and comfortable. I feel a tingling sense of relaxation in my legs.’” (Repeat this suggestion three to five times)

“Now notice your lower body. Notice the feelings in your buttocks, lower back, and lower stomach. Feel the weight of your body pressing into your chair. As you are feeling the weight of your body say to yourself: ‘My lower body is warm and comfortable. I feel a tingling sense of relaxation in my lower body.’” (Repeat this suggestion three to five times)

“Now notice your upper body. Notice the feelings in your chest and upper back. Feel the weight of your body pressing into your chair. As you are feeling the weight of your body say to yourself: ‘My upper body is warm and comfortable. I feel a tingling sense of relaxation in my upper body.’” (Repeat this suggestion three to five times)

“Now notice your arms and shoulders. Notice the feelings in your arms and shoulders. Feel the weight of your arms as they rest comfortably on your lap. Notice the feeling of your arms gently pulling down on your shoulders. Notice any tension in your arms and shoulders and, if it is comfortable to do so, adjust your arms and shoulders to release the tension and become more relaxed.”

“As you are feeling the feelings in your arms and shoulders, say to yourself: ‘My arms and shoulders are warm and comfortable. I feel a tingling sense of relaxation in my arms and shoulders.’” (Repeat this suggestion three to five times)

“Now notice your neck. Notice the feelings in your neck. Notice any tension in your neck and, if it is comfortable to do so, adjust your neck by rotating it gently to release the tension and become more relaxed.”

“As you are feeling the feelings in your neck, say to yourself: ‘My neck is warm and comfortable. I feel a tingling sense of relaxation in my neck.’” (Repeat this suggestion three to five times)

“Now notice your head and scalp. Notice the feelings in your head and scalp. Imaging your scalp tingling with a warm sense of relaxation.”

“As you are feeling the feelings in your head and scalp, say to yourself: ‘My head
and scalp is warm and comfortable. I feel a tingling sense of relaxation in my head and scalp.’” (Repeat this suggestion three to five times)

“Notice your face. Notice any tension in your face. Notice your jaw and allow it to relax. Feel how heavy your jaw is becoming and allow your jaw to relax. If it is comfortable to do so, adjust your jaw by rotating it gently to release the tension and become more relaxed. Notice the feelings around your eyes. If it is comfortable to do so, move the muscles around your eyes to release any tension.”

“As you are experiencing the feelings in your face, jaws, and eyes, say to yourself: ‘My face, jaws, and eyes are warm and comfortable. I feel a tingling sense of relaxation in my face, jaws, and eyes.’” (Repeat this suggestion three to five times)

Deep Breathing

“Notice your breathing. Notice how your breath flows in and out of your body. Notice that you can regulate how quickly or slowly you breath. Take a deep breath, hold it for a moment until your lungs feel tense, then slowly exhale. Take another deep breath, hold it for a moment until your lungs feel tense, then slowly exhale. One more time. Take another deep breath, hold it for a moment, slowly exhale.”

“Notice if you are breathing from high in your chest or low in the stomach. As you notice your breathing, lower the breathing deep into your stomach. Imagine your lower stomach going in and out with each breath you take.”

Rhythmic Breathing

“Now, as you are listening to my voice and noticing yourself relax, slowly breath in to the count of four and out to the count of four. As you breath in allow your breathing to fill the lower part of your stomach. As you breath out feel the lower part of your stomach relax. Inhale … one, two, three, four .— exhale … one, two, three, four …hold it a moment.” (Repeat this for five to ten breaths)

Visualizing the Triangle and Ball

“Now, visualize a black background before your eyes. See a bright red triangle, pointing up, with equal sides appearing on this deep black background. See the deepness of the red color within the triangle.”

“Now imagine a bright yellow ball at the bottom right hand side of the triangle. Imagine the ball rolling slowly up to the top of the triangle as you count slowly to four. Bring the ball up … one, two, three, four. Balance the ball at the top of the triangle. Bring the ball down … one, two, three, four.” (Practice this five to ten times).

Combining Breathing and the Triangle and Ball

“Now, as you see the ball rising to the top of the triangle take a very slow and deep breath. As your lungs fill with air, imagine the ball balancing at the top of the triangle. As you slowly exhale, imagine the ball slowly moving down the other side of the triangle.”

Inhale … raise the ball to the top of the triangle … hold it for moment—exhale … lower the ball to the bottom of the triangle.” (Practice this five to ten times)

Adding Relaxation Suggestions

“As you breath in and imagine the ball rolling to the top of the pyramid say to
yourself: ‘I am …’ as the ball rolls down the other side of the triangle say to yourself, ‘relaxing …’ ‘I am …’ Ball to the top. ‘Relaxing’ Ball to the bottom.” (Repeat five to ten times)

10. Waking Up From Relaxation

“Imagine that you are waking up in the morning from a deep and peaceful sleep. As you awaken you feel an urge to stretch and try to yawn. Take a deep, deep breath. Slowly come awake feeling the urge to stretch and yawn. Open your eyes, stretch your arms over your head. Come back fully awake feeling rested and alert.”

Relapse is more than just using alcohol or drugs. It is the progressive process of becoming so dysfunctional in recovery that self-medication with alcohol or drugs seems like a reasonable choice.

The relapse process is like knocking over a line of dominoes. The first domino hits the second, which hits the third, and soon a progressive chain reaction has started. The sequence of problems that lead from stable sobriety to relapse are similar to those dominoes, with two differences. First, each domino in the line (i.e. each problem that brings us closer to substance use) gets a little bit bigger and heavier until the last domino, or problem, in the sequence is 10,000 pounds. As this 10,000 pound domino begins to fall on us, it is too heavy for us to handle alone. The second difference is that the problems circle around behind us. So when the last domino or problem falls, it hits us from behind when we’re not looking.

So here we are, moving along in recovery. We encounter one small problem. No big deal! Then we encounter another problem. Soon a chain reaction begins. The first problems are so small that we can easily convince ourselves they’re no big deal. We look the other way and start doing other things. All of a sudden a huge problem falls on us and causes serious pain and injury. We need to make the pain go away and we reach for old reliable – the magical substances that always helped us with our pain in the past. We’ve now started drinking and drugging.

The answer to avoiding relapse is to learn how not to tip over the first domino, and take care of the little problems in life. Another part of the answer is to develop an emergency plan for stopping the chain reaction quickly, before the dominoes start getting so big and heavy that they become unmanageable.

The Relapse Process

The progression of problems that lead to relapse is called the relapse process. Each individual problem in the sequence is called a relapse warning sign. The entire sequence of problems is called a relapse warning sign list. The situations that we put ourselves in that cause or complicate the problems are called high risk situations.

It’s important to remember that we don’t start drinking and drugging because of the last problem in the sequence. We start drinking and drugging because the entire sequence of problems got out of control. Let’s look at this process:

Step 1: Getting Stuck In Recovery

Many of us decide that alcohol or drugs are a problem, stop using, and put together some kind of recovery plan to help us stay sober. Initially we do fine, but then we hit a problem that we are unwilling or unable to deal with. We stop dead in our tracks. We are stuck in recovery and don’t know what to do.

Step 2: Denying That We’re Stuck

Instead of recognizing that we’re stuck and asking for help, we use denial to convince ourselves that everything is OK. Denial makes it seem like the problem is gone, but it really isn’t. It just goes under ground where we can’t see it. We keep investing time and energy in denying it which results in a buildup of pain and stress.

Step 3: Using Other Compulsions

To cope with the pain and stress, we begin to use other compulsive behaviors. We may begin overworking, over-eating, dieting, or over-exercising. We can get involved in addictive relationships and distract ourselves with sex and romance. These behaviors make us feel good in the short run by distracting us from our problems. But they do nothing to solve the problem. We feel good now, but we hurt later. This is a hallmark of all addictive behaviors.

Step 4: Experiencing A Trigger Event

Then something happens. It’s usually not a big thing. It’s something we could normally handle without getting upset. But this time something snaps inside. One person described it this way: “It feels like a trigger fires off in my gut and I go out of control.”

Step 5: Becoming Dysfunctional On The Inside

When the trigger goes off, our stress increases, and our emotions take control of our minds. To stay sober we have to keep intellect over emotion. We have to remember who we are (an addicted person), what we can’t do (use alcohol or drugs), and what we must do (stay focused upon working a recovery program). When emotion gets control of the intellect we abandon everything we know, and start trying to feel good at all costs.

Relapse almost always grows from the inside out. The trigger event makes our pain so severe that we can’t function normally. We have difficulty thinking clearly. We swing between emotional overreaction and emotional numbness. We can’t remember things. It’s impossible to sleep restfully and we get clumsy and start having accidents.

Step 6: Becoming Dysfunctional On The Outside:

At first this internal dysfunction comes and goes. It’s annoying, but we learn how to ignore it. On some level, we know something is wrong, but we keep it a secret. Eventually we get so bad that the problems on the inside create problems on the outside. We start making mistakes at work, creating problems with our friends, families, and coworkers, start neglecting our recovery programs. Things just keep getting worse.

Step 7: Losing Control

We try to handle each problem as it comes along but miss the growing pattern of problems. We never really solve anything. It’s just band-aid after band-aid. Then we look the other way and try to forget about the problems by getting involved in compulsive activities that will somehow magically fix us.

This approach works for a while, but eventually things start getting out of control. As soon as we solve one problem, two new ones pop up. Life becomes one problem after another in an apparently endless sequence of crisis. One person put it like this: “I feel like I’m standing chest deep in a swimming pool trying to hold three beach balls underwater at once. I get the first one down, then the second, but as I reach for the third, the first one pops back up again.”

We finally recognize that we’re out of control. We get scared and angry. “I’m sober! I’m not drinking! I’m working a program! Yet I’m out of control. If this is what sobriety is like – who needs it?”

Step 8: Using Addictive Thinking

Now we return to addictive thinking. We begin thinking along these lines: “Sobriety is bad for me, look at how miserable I am. Sober people don’t understand me. Look at how critical they are. Maybe things would get better if I could talk to some of my old friends. I don’t plan to drink or use drugs, I just want to get away from things for a while and have a little fun. People who supported my drinking and drugging were my friends. They knew how to have a good time. These new people who want me to stay sober are my enemies. Maybe I was never addicted in the first place. Maybe my problems were caused by something else. I just need to get away from it all for a while! Then I’ll be able to figure it all out.”

Step 9: Going Back To Addictive People, Places, And Things

Now we start going back to addictive people (our old friends), addictive places (our old hangouts), and addictive things (mind polluting compulsive activities). We convince ourselves that we’re not going to drink or use drugs. We just want to relax.

A client in one of my groups said he wanted to go to a bar so he could listen to music and relax while drinking soft drinks. An old-timer in the group asked: “If you told me you were going to a whore house to say prayers, do you think I’d believe you?”

Step 10: Using Addictive Substances

Eventually things get so bad that we come to believe that we only have three choices – collapse, suicide, or self-medication. We can collapse physically or emotionally from the stress of all our problems. We can end it all by committing suicide. Or we can medicate the pain with alcohol or drugs. If these were your only three choices, which one sounds like the best?

At this stage the stress and pain is so bad that it seems reasonable to use alcohol or drugs as a medicine to make the pain go away. The 10,000 pound domino just hit. We’re dazed, and in tremendous pain. So we reach out for something, anything that will kill the pain. We start using alcohol and drugs in the misguided hope it will make our pain go away.

Step 11: Losing Control Over Use

Once addicted people start using alcohol or drugs, they tend to follow one of two paths. Some have a short-term and low consequence relapse. They recognize that they are in serious trouble, see that they are losing control, and manage to reach out for help and get back into recovery. Others start to use alcohol or drugs and feel such extreme shame and guilt that they refuse to seek help. They eventually develop progressive health and life problems and either get back into recovery, commit suicide, or die from medical complications, accidents, or drug-related violence.

Other Outcomes Of The Relapse Process

Some relapse prone people don’t drink. They may say “I’d rather be dead than drunk” and they either attempt or commit suicide. Others just hang in there until they have a stress collapse, develop a stress related illness, or have a nervous breakdown. Still others use half measures to temporarily pull themselves together for a little while only to have the problems come back later. This is called partial recovery and many people stay in it for years. They never get really well, but they never get drunk either.

What I have just described is called the relapse process and it’s not uncommon. Most recovering people periodically experience some of these warning signs. About half can stop the process BEFORE they start using substances or collapse from stress. The other half revert to using alcohol or other drugs, collapse from stress related illness, or kill themselves.

It’s not a pretty picture. No wonder we don’t want to think or talk about relapse. It’s depressing. The problem is that refusing to think or talk about it doesn’t stop it from happening. As a matter of fact ignoring the early warning signs makes us more likely to relapse.

But there is hope. There is a method called Relapse Prevention that can teach us to recognize early warning signs of relapse and stop them before we use alcohol and drugs, or collapse.

Post Acute Withdrawal (PAW) can be a serious problem for nearly 90% of people in recovery from chemical addictions. There is hope. There are some simple recommendation that can help you manage PAW symptoms. In severe cases and when coexisting disorders, especially depression, are present, there are medications that can help. Don’t be too quick to start medications. The consistent use of five simple and straight forward steps can make a big difference in reducing the frequency and severity of PAW symptoms episodes. Here are the recommended steps in managing PAW:

1. Accurate Information: Explain PAW and have the person do a self-evaluation of PAW and review the results. This will give them words and ideas to explain what they are experiencing. It will also help people to stop feeling crazy, judging themselves for having the symptoms, and being anxious and afraid because they don’t know what is happening. Everything that needs to be covered in a comprehensive recovery education program on Post Acute Withdrawal is presented in the Comprehensive Guide to PAW.

2. Stress Management, Relaxation and Meditation: PAW is stress sensitive. This means the symptoms get more severe when experience high stress and less sever under low stress levels. Mindfulness Meditation has been shown to be especially effective. (See the Blog: Mindfulness Made Simple)

3. Proper Diet: Have an alcohol and drug free diet. Eat a high protein, complex carbohydrate meal plan. The closest diet plan is a hypoglycemic diet. Ask a nutritionist or look it up the internet. Avoid foods high in sugar and limit your caffeine intake. Supplement with multiple vitamins,Vitamin B-12, and broad spectrum amino acids. (Eating Right To Live Sober is a book on solid no-nonsense nutrition principles that have stood the test of time.)

4. Aerobic Exercise: Doing heart-measured aerobic exercise at least twenty minutes per day, a minimum three-days per week in a heart-measured aerobic zone improves psychological well-being and overall health. To determine you aerobic training zone, subtract your age from 220. 80% of that number is you minimal training zone. 80% is the max). Too high or too low don’t seem to help much.

5. A Recovery Program: Have a regular schedule of recovery activities that put you in places and around people who support your recovery and where you can honestly talk about yourself without judgment. It is also important to having a sponsor/mentor and therapist trained as an addiction professional.

These practices seem to help stabilize brain chemistry, lower stress, and improve levels of self-esteem.

Don’t leave PAW management to chance.
Get a plan.
Work the plan.
If it doesn’t work, get additional help.

Please don’t spread the mistaken belief there is nothing that can be done to reduce the frequency and severity of PAW symptom episode. IT’S JUST IS NOT TRUE. The brain is plastic. It grows in response to experiences especially when stress in managed well during the experience.

The risk of relapse is an important factor in determining the type and level of care for addiction treatment. A useful tool called The AWARE Questionnaire has been developed been developed and is in its third revision based upon ongoing use (Miller et al 1996). This questionnaire provides an evidenced based approach for measuring the risk of relapse.

The AWARE Questionnaire (Advance WArning of RElapse) was designed as a measure of the warning signs of relapse, as described by Gorski (Gorski & Miller, 1982).

Gorski’s thirty-seven warning signs of relapse was originally developed as a result of clinical interviews with 117 patient conducted by Gorski. The patients were chronic stage gamma alcoholics who had completed at least one 28-day residential rehabilitation program for alcoholism and subsequently entered treatment again for alcoholism.

The AWARE Questionnaire (Advance WArning of RElapse) was designed as a measure of the warning signs of relapse, as described by Gorski (Gorski & Miller, 1982). In a prospective study of relapse following outpatient treatment for alcohol abuse or dependence (Miller et al., 1996) the researchers found the AWARE score to be a good predictor of the occurrence of relapse (r = .42, p < .001). With subsequent analyses, the researchers refined the scale from its 37-item original version to the current 28-item scale (version 3.0) (Miller & Harris, 2000).

The items are arranged in the order of occurrence of warning signs, as hypothesized by Gorski. In our prospective study, however, we found no evidence that the warning signs actually occur in this order in real-time (Miller & Harris, 2000). Rather, the total score was the best predictor of impending relapse.

This is a self-report questionnaire that can be filled out by the client. Be sure that the client understands the 1-7 rating scale. When the client has finished, make sure that all items have been answered and none omitted.

Scoring is completed by adding up the total the numbers circled for all items, but reversing the scoring for the following five items: 8, 14, 20, 24, 26. For these five items only. In other words, if the client circles this number: 1 2 3 4 5 6 7 Add this number to the total score: 7 6 5 4 3 2 1

INTERPRETATION: The higher the score, the more warning signs of relapse are being reported by the client. The range of scores is from 28 (lowest possible score) to 196 (highest possible score). The following table shows the probability of heavy drinking (not just a slip) during the next two months, based on our prospective study of relapse in the first year after treatment (Miller & Harris, 2000).

Probability of Heavy Drinking During the Next Two Months

AWARE
Score

If already drinking
in the prior 2 months

If abstinent during
the prior 2 months

28-55

37%

11%

56-69

62%

21%

70-83

72%

24%

84-97

82%

25%

98-111

86%

28%

112-125

77%

37%

126-168

90%

43%

169-196

>95%

53%

This instrument was developed through research funded by the National Institute on Alcohol Abuse and Alcoholism (NIAAA, contract ADM 281-91-0006). It is in the public domain, and may be used without specific permission provided that proper acknowledgment is given to its source. The appropriate citation is Miller & Harris (2000).